Uncertainties remain regarding the optimal screening pathway, frequency of follow-up imaging, candidate selection for thromboprophylaxis, and treatment strategies for post-MI LV thrombus. Ongoing studies from related therapeutic areas of varying antithrombotic regimens will continue to inform the optimal approach to treatment; however, more dedicated study of this clinical conundrum is also needed.

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31Aspirin is one of the most frequently used drugs worldwide and is generally considered effective 32 for the secondary prevention of cardiovascular disease (CVD). In contrast, the role of aspirin in 33 primary prevention of CVD is controversial. Early trials evaluating aspirin for primary 34 prevention, conducted before the turn of the millennium, suggested possible reductions in MI 35 and stroke, although not mortality, and an increased risk of bleeding. In an effort to balance the 36 risks and benefits of aspirin, international guidelines on primary prevention of CVD have 37 typically recommended aspirin only when there is a substantial 10-year risk of CV events. 38 However, recent, large randomized clinical trials of aspirin for the primary prevention of CVD 39 demonstrate little or no benefit and possible harm. In this narrative review, we reappraise the role 40 of aspirin in primary prevention of CVD contextualizing data from historical and contemporary 41 trials. 42 43 1897 ( Figure). 2 51 Almost a century later, in 1974, a randomized controlled trial showed a non-significant 52 reduction in deaths amongst patients with a recent myocardial infarction (MI) who were assigned 53 to aspirin 330mg/day. 3 This launched a series of trials that resulted in widespread acceptance of 54 aspirin for the secondary prevention of major adverse cardiovascular events (MACE). 4-11 55Enthusiasm for aspirin led to further randomized controlled trials investigating whether aspirin 56 might be effective for the primary prevention of cardiovascular disease (CVD). [12][13][14][15][16][17] Several 57 primary prevention trials, mostly conducted before the turn of the millennium, suggested 58 reduction in MI and stroke, although not mortality 16 , and at a cost of increased bleeding 59 events. 12-15 These findings influenced guidelines, which recommended prescribing aspirin for 60 primary CVD prevention in high-risk individuals. [18][19][20] Aspirin is now one of the most widely 61 used medications. In the U.S. alone, it is estimated that 35.8 million adults are taking aspirin for 62 the primary prevention of CVD, often without consulting their physicians. 23 63 Despite aspirin's popularity, its use for the primary prevention of CVD is controversial. 64Indeed, the U.S. Food and Drug Administration (FDA) has never approved the labeling of 65 aspirin for this purpose. The European Medicines Agency (EMA) have not addressed this 66 4 question. Furthermore, recent clinical trial data have placed the utility of aspirin for the primary 67 prevention of CVD back under scrutiny due to their neutral results 24,25 or evidence of harm. 26 In 68 this article, we summarize the mechanism of action, review historical and contemporary trials 69 evaluating aspirin, and reflect on future directions for aspirin in the prevention of CVD. 70 71 Search Strategy and Selection Criteria 72PubMed was used to identify relevant references using the search terms "aspirin", and "primary 73 prevention". We also searched all of the references in recent systemati...

Despite the many advances in cardiovascular medicine, decisions concerning the diagnosis, prevention, and treatment of left ventricular (LV) thrombus often remain challenging. There are only limited organizational guideline recommendations with regard to LV thrombus. Furthermore, management issues in current practice are increasingly complex, including concerns about adding oral anticoagulant therapy to dual antiplatelet therapy, the availability of direct oral anticoagulants as a potential alternative option to traditional vitamin K antagonists, and the use of diagnostic modalities such as cardiac magnetic resonance imaging, which has greater sensitivity for LV thrombus detection than echocardiography. Therefore, this American Heart Association scientific statement was commissioned with the goals of addressing 8 key clinical management questions related to LV thrombus, including the prevention and treatment after myocardial infarction, prevention and treatment in dilated cardiomyopathy, management of mural (laminated) thrombus, imaging of LV thrombus, direct oral anticoagulants as an alternative to warfarin, treatments other than oral anticoagulants for LV thrombus (eg, dual antiplatelet therapy, fibrinolysis, surgical excision), and the approach to persistent LV thrombus despite anticoagulation therapy. Practical management suggestions in the form of text, tables, and flow diagrams based on careful and critical review of actual study data as formulated by this multidisciplinary writing committee are given.